CSU - Intranet

Early Alert Program Referral Form

With this information, we can contact the student and encourage participation in student programs, tutorials, counseling, and/or workshops that may help the student academically or personally. Information you provide may be shared with the student, who has legal access to this information. Observations should be objectively stated.

Instructor's E-mail:
Instructor’s Name:		Office Ph. No.:
Student’s Name:		Date:
Student’s CSUID #:		Course:

Please check any statements that, in your judgment, describe this student:
Student lacks essential skills: reading, writing, math.
Student is not completing reading and/or homework assignments.
Student continually submits sub-standard work.
Student appears to struggle to keep pace with the class.
Student lacks aptitude in subject matter.
Student does not take class notes.
Student is not attending class.
Student is attending class but is not making satisfactory progress.
Student is not participating in class.
Student is not performing well on tests.
Student exhibits poor attitude and/or disruptive classroom behavior.
Other. Please explain:

Clarification of items checked above:

If you have any questions about the Early Alert Program, please contact the Academic Advising office at 568-2330.